It will be an honor to be a part of an Organization where integrity and ethical principles are critical to patient care. Commitment, on my part, is essential to the wellbeing of the community I desire to serve by providing quality care, nurturing support and fiscal responsibilities.
• Inpatient care- coordination of discharge planning to home health, DME, IV infusions, out pt therapy needs, submission of Prior auth for medication authorization request.
• Provide education for all transplant patients, inpatient and outpatient, for GI and hepatology services and assist in transition of care needs for all patients.
• Nurse care coordination- track, screen, monitor and coordinate the care of patients with multiple co-morbidities, psychosocial needs while continue to develop a patients’ action plan and discharge planning.
• Thrall reviews of services needed and determines medical appropriateness of inpatient and outpatient services following transplant evaluation.
• Work with multidisciplinary team on daily bases, during inpatient rounds and outpatient clinic for coordination of care.
• Responsible for clinical and medical management across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating).
• Includes case management, coordination of care, and medical management.
• Responsible for providing health education, coaching and treatment decision support for patients and family.
• Coordinator acts as an advocate for patients and their families while guiding them through the health care system for transition planning and longitudinal care before and after transplant.
• Coordinator works in close partnership with multiple disciplines including Social Worker.
• Identifies appropriate candidate upon referral and collaborates a multi-disciplinary team. Identifies requirements for candidate evaluation.
• Communicate with patient caregivers, and family to assure a well-organized and thrall action plan is established.
• Identify patient needs, ensure a close loop of communication is established.
• Develop action plan and prioritize goals.
• Utilization of evidenced-based practice, develop interventions while considering member barriers independently.
• Make referrals to community sources and programs identified for patients while working alongside Social work to make transition easier.
• Dailyn collaboration with Interdisciplinary Team to establish an individualized discharge /or transition plan for all patients.
• Able to Manage assigned caseload in an efficient and effective manner by utilizing time management skills.
• Enter timely documentation to comply with documentation requirements by UNOS.
• Maintain current RN licensure to work in state of employment and maintain hospital credentialing as indicated.
• Efficiently performs all other related duties as assigned.
• Coordinate inpatient admission for transplant surgery, and hepatobiliary related surgeries.
• Knowledge of ICD 10 and CPT coding.
• Coordinates with multidisciplinary team the evaluation process for transplant candidate, including, but not limited to:
Medical / surgical evaluation, psychosocial evaluation, Educational assessment, Laboratory evaluation, Radiological evaluation, Nutritional evaluation, Outreach Clinic Setting.
• Interprets serological results of the potential transplant and their implication for transplant.
• Obtains recipient blood type, tissue typing and cytotoxic antibodies according to transplant center protocol.
• Identifies possible co-morbidities in the transplant candidate and evaluate as indicated. Ensures that patient is assessed for presence of malignancy prior to listing
• Identifies absolute and relative contraindications to transplantation
• Ensures patient understands risk and benefit of immunizations required prior to transplantation.
• Functions as candidate advocate by applying knowledge of growth, development, educational and cultural background during candidate / family / legal guardian interactions.
• Educates candidate / family / legal guardian about: Living donation options Evaluation process
OPTN regulations, Organ allocation, waiting phase, Transplant process, Risks / benefits, including utilization of expanded donors, high-risk donors, if applicable. Post-operative phase including immunosuppressive therapy and effects. Potential research protocols of the transplant program. Candidate / family / legal guardian responsibility throughout the transplant process. CMS required disclosures such as SRTR, Medicare B, coverage, psychological risks, etc.
• Identifies and responds to the psychosocial and economic needs of the transplant candidate / family / legal guardian during evaluation.
• Collects and evaluates medical, psychosocial and financial data for review by the transplant team.
• Communicates with referring physicians, other health care providers, payers and transplant team members regarding the candidate’s status and evaluation outcome
• Demonstrates knowledge of, and compliance with OPTN/UNOS policies and listing requirements
• Informs and educates patient / family / legal guardian at time of listing
• Ensures patient and referring physician are informed in writing of transplant listing, denial or postponement
• Acts as resource person for internal and external health care providers.
• Provides and maintains comprehensive documentation of evaluation process and makes appropriate referrals to specialists.
• Provides data to OPTN/UNOS for listing statistics.
• “Presents” candidate to selection committee in an accurate manner to the satisfaction of the medical and surgical leadership.
• Assesses and documents candidate/family/legal guardian’s educational deficits of transplant process
• Develops and institutes a teaching plan addressing transplant candidate/family/legal guardian’s learning needs.
• Maintains/ensures communication with patient, referring physicians, payors, other health care providers and transplant team members.
• Recognizes potential problems, abnormal diagnostic findings and/or significant changes during the waiting phase, coordinating required care.
• Ensures cytotoxic antibody screen is obtained regularly per transplant center protocol. Maintains routine health maintenance and surveillance for malignancy during the waiting period.
• Identifies and responds to the psychosocial and economic needs of the transplant candidate/family/legal guardian during waiting phase
• Exhibits ability to maintain and update candidate-listing status per OPTN/UNOS regulations to include MELD updates with lab results dated closest to update
• Identifies the need for candidate re-evaluation and initiates when appropriate. Acts as resource person for internal and external health care providers
• Provides and maintains comprehensive documentation of candidate progress
• Identifies appropriate live donor candidate upon referral, and interacts with appropriate staff.
• Identifies requirements for and maintains confidentiality of the living donor evaluation.
• Ensures process of informed choice has been followed according to transplant center protocol.
• Coordinates with multidisciplinary team the evaluation process for the potential live donor candidate.
• Applies knowledge of growth, development, educational and cultural background during live donor candidate and family interactions.
• Educates live donor candidate and family about the evaluation, donation, and hospitalization process, risks and benefits, and short/long term follow-up care and documents accordingly.
• Identifies recipient learning needs, coping skills, decision-making process, long-term expectations and commitment regarding the donation process.
• Verbalizes understanding of live donor protocol, and acts as a resource for internal and external health care providers.
• Collects and reviews evaluation results with the transplant team. Participates in the determination of a potential live donor’s suitability to donate for transplant according to transplant center protocol and CMS/OPTN/UNOS regulations.
• Facilitates admission date with donor and transplant candidate, and notifies transplant team members of pending surgery.
• Assists family with adjustment for live donor recipient physical and emotional rehabilitation.
• Observes, monitors, reviews and reports live donor recipient physical and emotional status to the appropriate transplant team member.
• Maintains/ensures communication with recipient primary physician, other health care providers and payors throughout the evaluation phase, surgical procedure and postoperative recovery.
• Provides and maintains comprehensive documentation of live donor recipient progress according to transplant center protocol.
• Functions as donor advocate with other members of the transplant team.
Charge nurse for Oncology unit of 12 beds,
§ Mentored/ Precept new oncology nurses, sharing knowledge gained from years of experience in specialized cancer care settings.
§ Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
Staff Nurse Duties:
Staff Nurse - float to several HCA facilities
Methodist Children Hospital, Metro and stone oaks.
float to Pediatric Med-Surg/Pedi Intermittent Care Unit, Hematology Oncology, and NICU
Private Duty Nurse. All but not limited to all aspects of nursing care process
Care of Pediatric Patient Home Health needs
G-tube feedings, medication administration, Nebulizer treatment, Triology 100.
Monitors and assess all needs required for appropriate care of patients needs
Additonal Duties
monitor I&O’s, vital sign, room set up for seizure patients and new admissions, assist nurse in patient care, EKG’s, transport intubated patient to MRI,CT or any other medical procedure within the hospital, provide patient with ADL’s.
Clerk -Registration of new admissions, telephone techniques, discharge/admissions and transfers.
Float to other floors within the hospital as a Nurse Assistant
Trainings /course previously taken
APHON chemo course
Liver/Kidney (transplant)course
Cystic Fibrosis course
Central line course
Hematology/Oncology course
Diabetes course
American Heart Association BLS for Healthcare Providers (CPR & AED) PALS, Program American Heart Association ACLS Certification
Xochilt Castaneda – 210-831-2782 -co-worker
Stephanie Vera- 956-286-6917- co-worker
Raquel Gordon – 210-315-1664 -co-worker
Michell Reinarz- 210-704-2356- manager at Santa Rosa hospital
Chuchi Pontillano-210-264-4853- PCC
Xochilt Castaneda – 210-831-2782 -co-worker
Stephanie Vera- 956-286-6917- co-worker
Raquel Gordon – 210-315-1664 -co-worker
Michell Reinarz- 210-704-2356- manager at Santa Rosa hospital
Chuchi Pontillano-210-264-4853- PCC